Oral Health Needs and Strategies for Nursing Home Residents

1. Oral Health Needs and Strategiesfor Nursing Home Residents Luke Burroughs, RDH, MPH

2. The Unifying Goal

3. A Forgotten Class

4. Our Connection

5. Our Aging Population • Older Adults • Healthy vs. Unhealthy aging • Diversity increasing • Susceptibility • Institutions • Nursing homes—ADLs • Assisted living facilities—IADLs

12. Losing Independence • Home and transportation • Privacy and self care • Mobility and socializing • Choices and leisure • Dementia and isolation

13. Nursing Homes in America • Statistics (2014) • Nursing homes: 15,600 • For-profit ownership: 69.8% • Licensed beds: 1.7 million • Laws • Enforcement

14. Legal Requirements • Centers for Medicaid and Medicare Services—mandate without funding • Federal Requirements (since 1992) • 1) emergency and routine dental care • 2) internally or from external source for each resident • 3) assist in scheduling and transportation • 4) develop OH program (training, examination, care plan) • State regulations: Comparison of State Requirements

15. Barriers to Oral Care • Responsibility • Training • Neglect • Ignorance • Time • Staffing

16. Barriers—Staff • Not trained adequately • University of Kentucky: https://dentistry.uky.edu/nursing-home-oral-health • Strategies for resistant residents are not understood • Texas Medical Foundation: • https://www.tmf.org/Health-Care-Providers/Nursing-Homes/Smile-Proud-Oral-Health-Project • Too many residents and patient care tasks • Oral hygiene nursing aide intervention • Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci DJ. Modification of Risk of Mortality from Pneumonia with Oral Hygiene Care, J Am GerSoc, 2008, 56 (9): 1601-1607.

17. Barriers—Self-Care Limitations • Disability, Depression, and Dementia • “Individuals with dementia have a right to good oral health. Oral health problems can and do impact upon their general health and quality of life, causing pain and disrupting their lives. Oral health is an integral part of their overall wellbeing and is essential for comfortable eating, speech, socializing and quality of life.” —The World Federation of Public Health Associations

18. Barriers—Health Literacy • Most U.S. adults cannot use printed health materials and tools with accuracy and consistency • Older adults more than twice as likely to lack health literacy • CDC recommendations: • Address expectations • Improve environment • Improve oral and print communication

19. Barriers—Insurance Gap • Benefits lost at retirement • 12% on Medicare have some dental insurance • Medicare—no routine dental care • Advocates are trying • Medicaid—no dental required for seniors or disabled • Varies by state, poor dentist participation • Lower SES—less preventive and restorative when younger

20. Barriers—Geriatric Dental Education • National Institute on Aging (1987)—need by 2000 (never achieved) • 1,500 geriatric dental teachers and 7,500 dental practitioners • Clinical geriatric training in dental programs—23% • CODA: “Graduates must be competent in providing oral health care within the scope of general dentistry to patients in all stages of life.” • Mini-residency in Nursing Home and Long-Term Care for the Dental Team (University of Minnesota)

21. Poor Oral Health in Nursing homes • Lack intact dentition (20+ Teeth) • Mortality • Diet and malnutrition • Socialization and self-esteem • High oral bacterial load • Aspiration pneumonia • Stress, depression, dementia risk

22. #1 Cause of Death in Nursing Homes? • 2008 Florida study: Nursing home residents who had daily mouth care provided by nursing assistants whose only job was to provide oral care had much less risk (3 times less risk) of dying from pneumonia than those residents who did not receive the daily care from the nursing assistant designated to do oral care. • Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci DJ. Modification of Risk of Mortality from Pneumonia with Oral Hygiene Care, JAm GerSoc, 2008, 56 (9): 1601-1607.

23. Tooth Loss • Impact on quality of life • Functional dentition (WHO): 20 teeth • Average remaining (65+): 19 • Less edentulism • 31% (1988-94), 25% (1998-2004) 19% (2011-12) in 65+ • Inefficiency of dentures and partials • Disparities

24. Dental Caries • Caries experience and untreated decay • Public and policymakers • Concentrate on the young • root caries and tooth loss in older adults • prescription fluoride gel (5000 ppm) • Poor surveillance (institutionalized older adults) • NHANES (none), BRFSS (phone survey)

25. Periodontal Disease • Severity increases with age and SES • Pain, discomfort, tooth mobility, tooth loss • Early intervention critical but lacking • Diabetic patients • Poor glycemic control in diabetics—threefold risk • Txof periodontal disease—10-20% glycemic control improvement

26. Hyposalivation • Not normal aging • LTC: 8 daily drugs • Antimicrobials and minerals • Repercussions—enamel, periodontium, trauma, appliances, speech, eating • Needs • Daily oral care (documented) • prescription high-concentrated fluoride (rinse, gel, varnish)

27. Oral and Pharyngeal Cancer • Surveillance, Epidemiology, and End Results Program (SEER) data • 9,000 deaths/year • 43% new cases 65+ • Death rates—no improvement • 5-year survival—slight improvement • Risk factors—tobacco, alcohol, sunlight, age • HPV (oral increases with age)

28. Pain and Infections • Need routine dental visits • Oral pain • Eating, swallowing, talking • Quality of life—withdrawal—nutrition—health decline • Less sensitivity or awareness • Failure to report

29. Angela, CNA • CNAs • Compensation • Knowledge • Skills • Oversight • Priorities

30. Oak Meadows Nursing home • Nursing Homes • Other Settings • Guidelines • Funding • Enforcement • The Human Factor

31. The Oral Care Routine

32. Max • Parkinson’s disease • 14 natural teeth • Root caries • Malnourished

33. Cora • Stroke • Speech impairment • Partials • Needs assistance with ADLs

34. Sam • Independent • Ambulatory • Mild cognitive impairment • Oral cancer

35. Mary • Alzheimer’s disease • Ambulatoy • Fearful • Total care

36. Henry • Arthritis • Chronic pain • Hyposalivation • Cariogenic snacks

37. Addie • COPD • Non-ambulatory • Multiple carious lesions • Shortness of breath

38. Meeting The Needs Of Seniors • The Dental Lifeline Network—comprehensive dental care (most states) • Low-income elderly or disabled with volunteer dentists • Dental Housecalls Program—on-site comprehensive care, elderly (Colorado) • Homebound, daycare, residential, nursing home facilities • Apple Tree Dental—Long-term care and meal sites (Minnesota, California) • Mobile and portable comprehensive dental care

39. Dental Treatment for Residents • Resident to dental office—expensive and inefficient • Equipment & staff to facility—on-site, familiar, interdisciplinary • ASTDD: https://www.mobile-portabledentalmanual.com/ • Virtual Dental Home: https://dental.pacific.edu/departments-and-groups/pacific-center-for-special-care/innovations-center/virtual-dental-home-system-of-care • Care coordination: shared records, oral health care coordinator

40. Public Health Strategies:1. Improve surveillance • Regional/statewide nursing home surveys • ASTDD Basic Screening Survey for Older Adults http://www.astdd.org/basic-screening-survey-tool/#adults • Survey private practice and safety-net providers • Train LTC staff in oral health assessment • Oral cancer screenings (on site)

41. Public Health Strategies:2. Stakeholder input and resources • ElderSmile (NY)—screening and referral at senior centers • Apple Tree Dental (MN, CA)—mobile and portable dental programs • Coalition for Oral Health for the Aging (Michigan)—advocacy, professional and public education, research • Oral Health America’s Wisdom Tooth—foundations and industry • Educational programs for older adults and caregivers

42. Public Health Strategies:3. Educate seniors and caregivers • Overcoming Obstacles to Oral Health (ADA and University of the Pacific)—Industry and academia • Health literacy and cultural considerations • Caregivers of patients with dementia—daily care and professional access • Advocate for insurance coverage for prescription fluoride • Stakeholders—prioritize older adult oral health

43. Public Health Strategies:4. Geriatric Dental Education • More clinical education • ADEA: series on geriatric dentistry. • Geriatric training residencies and specialties • Geriatrics programs for RDHs (University of Minnesota) • https://www.dentistry.umn.edu/continuing-dental-education/courses/miniresidency-nursing-home-and-long-term-care-dental-team • Continuing education in geriatric dentistry

44. Public Health Strategies:5. Expand Dental coverage • Dental care benefits or option in Medicare • Oral health care for institutionalized seniors on Medicaid • Special Care Dentistry Act • Increase reimbursement and covered services

45. Public Health Strategies6. Dental-Medical Health Home • Oral health guidelines for settings and disciplines • Community advocacy • Medicare coverage and Special Care Dentistry Act • Fluoride varnish and water fluoridation • Mobile and portable dental care • RDH—collaborative practice and telehealth

46. Public Health Strategies7. LTC Oral Health Regulations • Reimbursement (federal and state Medicaid) • Preventive services and fluorides (seniors) • Oral health regulations • Compliance • Extend regulations to assisted living and hospice facilities • State mandate—oral health assessments and plans

47. Independent Residents • Reminder • Verbal • Written • Label oral care items • Monitor for changes • Still perform assessments

48. Residents after Stroke • Blood flow interruption • Part of brain dies • Paralysis on one side • motor and sensory • Face and mouth • Swallowing difficulty and one-sided • Denture—retention and sores

49. Residents after Stroke • Dominant side—toothbrush grip • Collis Curve brush • Ask resident if they can brush • Independence vs helping • Eye level • Speak slowly, no “baby talk” • No distractions

50. Residents after Stroke • Vision and hearing • Help from “good side” • Speak up or hearing device • Notepad • Hand over hand • Speech, memory, and cognition • Emotions—anger, sadness, fear